The presence of dysphagia, odynophagia, unexplained weight loss, recurrent vomiting leading to dehydration, occult or gross bleeding, or a palpable mass or adenopathy are all “alarm” signals that demand directed radiographic, endoscopic, and surgical evaluation. Pts without alarm features are generally treated empirically. Individuals >45 years can be tested for the presence of H. pylori. Pts positive for the infection are treated to eradicate the organism. Pts who fail to respond to H. pylori treatment, those >45 years old, and those with alarm factors generally undergo upper GI endoscopy.
Treatment: Indigestion Weight reduction; elevation of the head of the bed; and avoidance of large meals, smoking, caffeine, alcohol, chocolate, fatty food, citrus juices, and NSAIDs may prevent GERD. Antacids are widely used. Clinical trials suggest that proton pump inhibitors (omeprazole) are more effective than histamine receptor blockers (ranitidine) in pts with or without esophageal erosions. H. pylori eradication regimens are discussed in Chap. 147. Peptic Ulcer and Related Disorders. Motor stimulants like metoclopramide and erythromycin may be useful in a subset of pts with postprandial distress. Surgical techniques (Nissen fundoplication, Belsey procedure) work best in young individuals whose symptoms have improved on proton pump inhibitors and who otherwise may require lifelong therapy. They can be used in the rare pts who are refractory to medical management. Clinical trials have not documented the superiority of one over another. Dietary exclusion of gas-producing foods (i.e., low FODMAP [fermentable oligosaccharide, disaccharide, monosaccharide, and polyol] diets), and therapies to modify gut flora can reduce symptoms but efficacy is unproven. |
For a more detailed discussion, see Hasler WL: Nausea, Vomiting, and Indigestion, Chap. 54, p. 258, in HPIM-19. |
Section 3. Common Patient Presentations